What makes a good death

Death: what is it, when does it come?

Odilon Redon: The Bark, around 1900, oil on canvas, 65 x 50.5 cm

An interdisciplinary workshop at King’s College London dealt with the subject of death and dying.

Some people think death is terrible. Others have no objection to it as long as it does not cause them pain. One can claim that life is all one has, or one can think of death as a mere emptiness with no value whatsoever. But if death comes as the inevitable end of existence for all people, why do we even ask whether it is bad to die? (1)

Recently, doctors and philosophers met for the second time in London as part of the “Philosophy of Medicine Workshop”: The event focused on the subject of death. A year earlier, British researchers had established a first meeting on the subject of “concepts of health and disease” at the “King’s College Center for the Humanities and Health” (2).

“Get used to believing that death means nothing to us. Because everything that is good and everything that is bad is a matter of perception. But the loss of perception is death. Therefore, the correct realization that death has no meaning for us makes the transience of life a source of pleasure, in that it does not promise us an unlimited time, but instead abolishes the desire for immortality. The most gruesome of all evils, death, has no meaning for us; for as long as we are there, death is not there, but if death is there, then we are not there ”(3). James Warren, philosopher at the University of Cambridge, introduced his remarks with this famous quote from Epicurus. Does death really mean nothing?

When do we die? What is the time of death that occurred? Is it brain death? Andrew Morley, chief anesthesiologist at St. Thomas Hospital in London, argued disturbingly. The criteria for successful deep anesthesia are the same as those for brain death: lack of brain activity and an isoelectric EEG. The anesthesia is reversible, that alone is the measurable difference. But, contrary to our imagination, does one perceive something in deep anesthesia? Does anesthesia actually ensure unconsciousness? Morley explained an experiment: anesthetized patients were cut off far above the arm artery. So she could no longer achieve a muscle relaxant on this extremity. "Now move your hand." The subjects did, but couldn't remember it when they woke up.

What does it mean to be alive? What can a “good” death be? Iona Heath, President of the Royal College of General Practitioners, introduced these questions with literature. She was inspired by Primo Levi (4), Susan Sontag (5) and Samuel Beckett (6), among others. Geoffrey Scarre, professor of philosophy at the University of Durham, spoke about dying. Not every dying necessarily ends in death. Miracles are still happening, people survive infinite predictions. Because of this, Scarre said, individuals could die multiple times. Dying is not universal, every person dies in his or her own way. Scarre imagines the end of life as a closed circle, he understands it as exhaustive completion. Death can perhaps also reveal itself as a gift, as a release from serious illness and suffering. Our current culture requires constant expansion of our selves. We climb higher and higher mountains, jump headfirst from rocks, and have surgery to look young for a long time. In this context, death must be a catastrophe because the circle can never come full. We are always missing something.

In the opera “Makropulos Case” the singer Emilia Marty is the daughter of the Greek doctor Makropulos, who tests his elixir of life on her. Now she is already 342 years old and is very bored in her endless life. “In the end everything is always the same: singing and silence.” Finally Emilia refuses the potion and she dies. David Galloway, of the Department of Philosophy at King’s College, by no means sees death as just an enemy. Emilia's problem was boredom. Everything that could have happened to her, she had seen before.

Rob George, professor of palliative medicine, said: "We die of a life, not of an illness." It is also the role of medicine to help patients die. “In comfort.” Means bringing a life to an end, understanding the journey, saying goodbye, apologizing and thanking wherever it appears necessary. To go in peace. But we humans are inhabited by pain and the resistance to dying. Pain changes us, but at the same time it can be influenced. Not just with analgesics. Social influences and our environment also change the intensity. For example, loneliness and isolation lower the pain threshold.

In Great Britain we know the tragic case of Anthony Bland, who, as a 17-year-old Liverpool fan, was seriously injured in the stadium during a crowd. He was in the "Persistent Vegetative State" for three years and his fate was tried before three courts. The decisive question was whether the doctors treating him were obliged to eat him or whether the treatment could be discontinued. The British "House of Lords" saw no medical obligation to continue in this case.

The legal scholar Roger Brownsword finally asked whether there could be a property right for parts of the body, similar to that for a ballpoint pen or a piece of land. Brownsword postulated: "I’m both, I am my body and have my body." We are objects and possessions at the same time, which distinguishes us from mere property. Ultimately, there remains ignorance about death. We suspect and continue to grope in the dark. However, a properly conducted discourse can help to light the way.

Dr. med. Svenja Ludwig

Nagel, Thomas: Mortal Questions, 1979.
Kingma E, Chisnall B, McCabe MM: Interdisciplinary Workshop on Concepts of Health and Disease: Report. Journal of Evaluation in Clinical Practice 2011;
17: 1018-22. CrossRefMEDLINE
Letter to Menoikeus. In: Nickel, Rainer: Epikur, 2005. S.121.
Levi, Primo: If this is a Man, 1958.
Leibovitz, Annie: A Photographer’s Life. 1990-2005, 2009.
Beckett, Samuel: Malonie Dies, 1951.